Case reports are considered as the lowest level of evidence while at the same time they are frontiers of evidence collection. case reports are professional stories about novel medical events and will worth publication only if they possess complexity، proper data collection، justified diagnosis، and legitimate intervention as well as appropriate language، punctuation، and syntax. A case report must clearly reflect the author’s reputation and proficiency in both practice and writing....

Background: Patient concerns represent opportunities for improvement in orthopaedic care. This study’s objective is to identify the nature and prevalence of unsolicited patient complaints regarding orthopaedic care at a tertiary referral hospital. The primary null hypothesis that there are no demographic factors associated with complaint types was tested. Secondarily we determined if the overall complaint number and types differed by year.

Methods: Complaints to the hospital ombudsperson by orthopaedic patients between January 1997 and June 2013 were reviewed. All 1118 complaints were categorized: access and availability، humaneness and disrespect، communication، expectations of care and treatment، distrust، billing and research.

Results: Patients between 40 and 60 years of age filed the most complaints in all categories except distrust (more common in patients over age 80) and research. Women were slightly more likely to address access and availability، humaneness، disrespect، and billing compared to men. The overall number of complaints peaked in 1999. The most common issue was access and availability followed by communication، and humaneness/ disrespect.

Conclusion: Half of concerns voiced by patients addressed interpersonal issues. The largest category was related to access and availability. Quality improvement efforts can address technology to improve access and availability as well as empathy and communication strategies.

Background: Little is known about how to introduce complex technologies like arthroscopy into low-income countries. Thus، we compared low- versus high-resource intensive methods of teaching basic arthroscopic skills in a randomized controlled trial in Haiti.

Methods: Forty-eight Haitian orthopaedic surgeons and residents attending an orthopaedic conference in Haiti were block randomized to receive instruction through a composite video (Control) or a composite video plus hands-on teaching with an expert visiting surgeon (Intervention). A low-fidelity surgical simulator tested visualization and triangulation skills. Participants completed a pre- and post-test where the goal was to sequentially tap the most numbers in 2.5 minutes. Outcome metrics included highest tapped number، number of errors، visualization loss، and number of lookdowns.Multivariate linear regression was used to confirm randomization and compare outcomes between groups.

Results: Seventy-five percent of initially randomized attendees participated with similar attrition rates between both groups. All participants who performed a pre-test completed a post-test. In terms of highest tapped number، treatment and control groups significantly improved compared to pre-test scores، with mean improvement of 3.2% (P=0.007) and 2.2% (P=0.03)، respectively. Improvement between treatment and control groups was not statistically different (P=0.4). No statistically significant change was seen with regard to other metrics.

Conclusion: We describe a protocol to introduce basic arthroscopic skills in a low-income country using a low-resource intensive teaching method. However، this method of learning may not be optimal given the failure to improve in all outcome measures.

Background: While various radiographic parameters and application of manual/gravity stress have been proposed to elucidate instability for Weber B fibula fractures، the prognostic capability of these modalities remains unclear. Determination of anatomic positioning of the mortise is paramount. We propose a novel view، the Gravity Reduction View (GRV)، which helps elucidate non-anatomic positioning and reducibility of the mortise.

Methods: The patient is positioned lateral decubitus with the injured leg elevated on a holder with the fibula directed superiorly. The x-ray cassette is placed posterior to the heel، with the beam angled at 15˚ of internal rotation to obtain a mortise view. Our proposed treatment algorithm is based upon the measurement of the medial clear space (MCS) on the GRV versus the static mortise view (and in comparison to the superior clear space (SCS)) and is based on reducibility of the MCS. A retrospective review of patients evaluated utilizing the GRV was performed.

Results: 26 patients with Weber B fibula fractures were managed according to this treatment algorithm. Mean age was 50.57 years old (range: range:18-81، SD=19). 17 patients underwent operative treatment and 9 patients were initially treated nonoperatively. 2 patients demonstrated late displacement and were treated surgically. Using this algorithm، at a mean follow-up of 26 weeks، all patients had a final MCS that was less than the SCS (final mean MCS 2.86 mm vs. mean SCS of 3.32) indicating effectiveness of the treatment algorithm.

Conclusion: The GRV is a novel radiographic view in which deltoid competency، reducibility and initial positioning of the mortise are assessed by comparing a static mortise view with the appearance of the mortise on the GRV. We have developed a treatment algorithm based on the GRV and have found it to be useful in guiding treatment and successful at achieving anatomic mortise alignment.

Background: Management of acetabular fractures in the senior population can be one of the most challenging injuries to manage. Furthermore، treating surgeons have a paucity of information to guide the treatment in this patient population. The purpose of this study was to determine: (1) demographic and epidemiologic data، 2) mortality rates for nonoperative compared to operative management at different time points، (3) common fracture configurations، and (4) fracture fixation strategies in senior patients treated with acetabular fractures.

Methods: Retrospective review of prospectively gathered data at a Level I trauma center over a five-year period. 1123 acetabular fractures were identified. 156 of them were for patients over the age of 65 (average age of 78).

Results: Falls and motor vehicle accidents accounted for the two most common mechanisms of injury. 82% of patients had significant medical comorbidities. 51 patients (33%) died within one year، in which 75% of them died within 90 days of their acetabular fracture. 84% of the deceased patients، i.e. from the group of 51 patients، had non-operative treatment. For patients treated with traction alone، there was a 79% one-year mortality and 50% mortality rate within 90 days. Within the entire cohort، 70% had either an associated both-column (ABC) or anterior column/posterior hemitransverse (AC/PHT) fracture pattern. Fifty-seven patients (36.5%) underwent open reduction and internal fixation using standard reduction techniques and surgical implants via two main surgical exposures of ilioinguinal (69%) and Kocher-Langenbeck (29%).

Conclusion: Geriatric patients with acetabular fractures are uncommon accounting for only 14% of all acetabular fractures. Patients who undergo surgery show lower mortality rates. ABC and AC/PHT fracture patterns are the two most common fracture patterns. Routine fixation constructs and implants can be used to manage these challenging fractures. Most patients are unable to return to their homes and instead require skilled nursing facility during their convalescence.

Background: Proximal Femoral shaft fractures are commonly associated with marked blood loss which can lead to postoperative acute anemia and some other complications. Tranexamic acid (TA) is an antifibrinolytic medication that reduces intra-and postoperative blood loss and transfusion requirements during some elective surgeries (1-3). The aim of this study is to evaluate the effect of intravenous Tranexamic acid (TA) on intraoperative blood loss and a subsequent need for transfusion in patients who were undergoing surgery for femoral shaft fractures in trauma setting.

Methods: Thirty-eight ASA grade I-II patients undergoing proximal femoral shaft fracture surgery with intra medullary nailing were included in this double blind randomized controlled clinical trial. They were allocated into two groups. Group I، the intervention group with eighteen patients received 15 mg/kg (TA) via intravenous infusion before surgical incision. Patients in the placebo group received an identical volume of normal saline. Hemoglobin level was measured four hours before and after the surgeries. Postoperative blood loss and hemoglobin change as well as transfusion rates and volumes were compared between the two groups.

Results: Mean Percentage fall in hemoglobin after surgery were 1.75±0.84 and 2.04±1.9 in the study and placebo groups، respectively ( P=0.570 ). Hemoglobin loss was higher in the placebo group. Transfusion rates was lower in TA group (5.6%) compared to the placebo group (30%) ( P=0.06 ). No significant difference in The Allowable Blood Loss during the surgery was found between the two groups ( P=0.894 ).

Background: Knee extension contracture is a disabling complication after fractures around the knee. In this study we aimed to study factors influencing the outcomes of quadricepsplasty for the treatment of traumatic knee extension contracture. We hypothesized that there is no factor influencing the final range of knee motion.

Methods: In this retrospective study، we included 64 patients who underwent modified Thompson quadricepsplasty between 2008 to 2011 with a mean follow-up time of 36 months.

Results:The mean change in flexion was 66 degrees. Using Judet criteria، results were excellent in 41 patients (64%)، good in 15 (23%)، fair in 4 (6%) and poor in 4 (6%). Preoperative arc of flexion، duration of extension contracture، number of previous surgeries on the limb، and BMI of the patients were independently influencing the final flexion.

Conclusion: Modified Thompson quadricepsplasty is associated with high number of excellent and good results especially when it is performed earlier in more severe contractures. Preoperative arc of flexion، interval between trauma surgery and quadricepsplasty، the number of prior surgeries، and BMI influence the outcomes of quadricepsplasty.

Among the power drills ( Electrical/ Pneumatic/Battery ) used in Orthopedic surgery، battery drill has got several advantages. Surgeons in low resource settings could not routinely use Orthopedic battery drills (OBD) due to the prohibitive cost of good drills or poor quality of other drills. “Hardware” or Engineering battery drill (HBD) is a viable alternative to OBD. HBD is easy to procure، rugged in nature، easy to maintain، durable، easily serviceable and 70 to 75 times cheaper than the standard high end OBD. We consider HBD as one of the cost effective equipment in Orthopedic operation theatres.

Synovial chondromatosis affecting the glenohumeral joint is rare. Treatment primarily consists of arthroscopic loose body removal and synovectomy. Shoulder arthroplasty has been mentioned in the literature as a treatment option for patients with coexisting arthritis، although the results have been underreported. The case of an 84-year-old man with long standing synovial chondromatosis of the shoulder resulting in severe degenerative disease is presented. The patient was treated with a reverse total shoulder arthroplasty، loose body removal، and a complete synovectomy. Three and six month follow up results have shown a decrease in the visual analogue scale for pain، improved range of motion، and no radiographic evidence of disease recurrence. Reverse total shoulder arthroplasty is a viable treatment option for synovial chondromatosis in patients with coexisting glenohumeral arthritis demonstrating good short term outcomes.

Recurrent dislocation is not common in small joints. This report presents a new case of chronic recurrent dislocation of proximal interphalangeal joint of the finger in which soft tissue injuries have a role in the dislocation. The patient was a 23 years old man who had referred to our center because of recurrent dislocation of proximal interphalangeal joint of his right ring finger during sports activities. This case was unique since no flexor digitorum superficialis or flexor digitorum profundus tendons were used for reconstruction of volar plate avulsion in the treatment.

Background: This is to assess one of the rare complications after total knee replacement and to assess risk factors of failure.

Methods: 11 patients with varus knee and an average age of 67 years underwent TKA between 2005 and 2013. All patients returned with a sudden sharp knee pain، disability to walk and significant decrease in ROM about 4 to 8 weeks after surgery. Radiographic examination revealed a lateral femoral condylar stress fracture.

Results: After analyzing the images، we found common characteristics among all patients، which might be attributable to the later fracture including varus deformity>25، femoral component lateralization، and valgus correction.

Conclusion: Surgeons should be aware of the risk factors to consider before، during، and after surgery.